adult ccrn/ccrn e/ccrn k certification review course: multisystem · 2016-02-03 · certification...

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Multisystem Multisystem Adult CCRN/CCRNE/CCRNK Certification Review Course: Multisystem Carol Rauen RNBC, MS, PCCN, CCRN, CEN Multisystem Bariatric complications Comorbidity in patients with transplant history End of life and palliative care Healthcareacquired infections (eg, central lineassociated bloodstream infection [CLABSI], catheterassociated UTI [CAUTI], ventilatorassociated pneumonia [VAP]) Infectious diseases Multiple organ dysfunction syndrome (MODS) Multisystem trauma Pain Rhabdomyolysis Sepsis continuum Shock states Sleep disruption (including sensory overload) Thermoregulation Toxic ingestions/inhalations Toxin/drug exposure (including allergies) Multisystem 8% 20% 80% 14% 12/2015 Multisystem 1

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Multisystem

Multisystem

Adult CCRN/CCRN‐E/CCRN‐K Certification Review Course:

Multisystem

Carol RauenRN‐BC, MS, PCCN, CCRN, CEN

Multisystem

Bariatric complications

Comorbidity in patients with transplant history

End of life and palliative care

Healthcare‐acquired infections (eg, central line‐associated bloodstream infection [CLABSI], catheter‐associated UTI [CAUTI], ventilator‐associated pneumonia [VAP])

Infectious diseases

Multiple organ dysfunction syndrome (MODS)

Multisystem trauma

Pain

Rhabdomyolysis

Sepsis continuum

Shock states

Sleep disruption (including sensory overload)

Thermoregulation

Toxic ingestions/inhalations

Toxin/drug exposure (including allergies)

Multisystem

8%20%

80%

14%

12/2015

Multisystem 1

Multisystem

Holistic Nursing CareOverdose CareMultisystem Care/ComplicationsShock Continuum

Multisystem

Pain

Palliative care

End‐of‐life care

Holistic Nursing Care

Multisystem

“Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” 

McCaffery and Beebe (1989)

Pain

McCaffery M, et al. Pain: Clinical Manual for Nursing Practice. 1989. 

12/2015

Multisystem 2

Multisystem

Physiology

Types

Assessment

Management

Pain (cont)

Multisystem

Palliative care

End‐of‐life care

Holistic Care 

Multisystem

Absorption

Distribution

Metabolism

Elimination

Toxic Ingestion/Inhalations/Drug Exposure

12/2015

Multisystem 3

Multisystem

Primary survey ABCs

DE and poison control

Secondary survey Level of consciousness (LOC)

Heart rate, respiratory rate, blood pressure

Temperature

Salicylates and cocaine

Barbiturates and opiates

Assessment

Multisystem

Full system assessment

History

Environment/bystanders

AMPLE  Allergies

Medications

Past illnesses

Last meal

Events

Assessment (cont)

Multisystem

Diagnostic tests

Toxicology screens: blood, urine, gastric aspirate

CBC, chemistry, liver function tests, coagulation profile, arterial blood gases

Chest x‐ray, ECG

Abdominal x‐ray 

Pregnancy test

Assessment (cont)

12/2015

Multisystem 4

Multisystem

Rapid response

Unknown substance, unconscious victim

Dextrose 50% IV Hypoglycemia

Thiamine 100 mg IV

Wernicke‐Korsakoff syndrome

Naloxone 2 mg IV, IM, or ET

Narcotic antagonist

Treatment Options

Multisystem

Antidote

Prevent absorption 

Enhance elimination

Orogastric lavage

Emetics (not recommended)

Activated charcoal

Diuresis

Whole bowel irrigation

Hemodialysis

Treatment Options (cont)

Multisystem

Acetaminophen

Liver failure

N‐acetylcysteine (NAC, Mucomyst)

AssessmentNausea/vomitingRight upper quadrant painBleedingElevated liver function tests

TreatmentNACGastric lavageCharcoal

Toxic Exposure: Common Toxins

12/2015

Multisystem 5

Multisystem

Assessment Altered LOCAlcohol breathHistoryArterial blood gases

TreatmentProtect airwayNasogastric tube, lavageIV fluidsSeizure precautionsManage/treat electrolytes

Toxic Exposure: Common Toxins (cont)

Alcohol

Respiratory depression

No direct drug antidoteIV fluids

Seizures

Liver failure

Multisystem

Carbon monoxide

Hypoxia

Remove from exposureAdminister oxygen

Assessment Altered LOCHeadache, seizureFlu‐like complaints

Treatment100% oxygenHyperbaric oxygen

Replaces oxygen on hemoglobin

Toxic Exposure: Common Toxins (cont)

Multisystem

Cocaine

Sympathetic response

None

Assessment HypoxiaStrokeHead injuryHigh temperatureMyocardial infarction

TreatmentTreatment presentationBenzodiazepines—sedationVasodilators—hypertensionAcute confusional state treatmentProvide coolingSeizure treatment

Toxic Exposure: Common Toxins (cont)

12/2015

Multisystem 6

Multisystem

Cyclic antidepressants

Central nervous systemCardiovascularAnticholinergic

Sodium bicarbonatePhysostigmine

Assessment Electrocardiographic changesHypotensionAltered LOC

TreatmentSodium bicarbonateNasogastric lavageCharcoalTreat heart rhythm, pacemaker

Toxic Exposure: Common Toxins (cont)

Multisystem

Opiates

Cardiovascular and respiratory depression

Naloxone

Assessment Decreased heart rateDecreased blood pressureDecreased respiratory rate

TreatmentAdminister naloxone

Toxic Exposure: Common Toxins (cont)

Multisystem

Salicylate

Respiratory stimulation

No direct drug antidoteSodium bicarbonate

Assessment HyperventilationRespiratory alkalosisMetabolic acidosisNausea/vomitingHyperpyrexiaBleeding

TreatmentArterial blood gasesBlood levelsChemistry, coagulation profileNasogastric lavage, charcoalIV fluidsTreat metabolic derangementLower temperatureTreat seizuresHemodialysis

Metabolic acidosis

Hyperthermia

Hypoglycemia

Platelets—bleeding

Toxic Exposure: Common Toxins (cont)

12/2015

Multisystem 7

Multisystem

Review Questions

Multisystem

A. Charcoal

B. NAC

C. Acute hemodialysis

D. Gastric lavage

Question 1

All of the following are anticipated treatments for acetaminophen overdose except:

Multisystem

Question 1—Rationale

C. Acute hemodialysis—Acetaminophen is not dialyzable, unfortunately

Charcoal—Might help to decrease absorption

NAC—Only agent used as an antidote

Gastric lavage—Might help to enhance elimination and decrease absorption

All of the following are anticipated treatments for acetaminophen overdose except:

12/2015

Multisystem 8

Multisystem

A. Chest pain, hypothermia, hypoxia

B. Tachycardia, chest pain, hyperthermia

C. Hyperthermia, hypotension, drowsiness

D. Anxiety, hypertension, hematuria

Question 2

When assessing a patient with suspected cocaine intoxication, a nurse would expect to see:

Multisystem

Question 2—Rationale

B. Tachycardia, chest pain, hyperthermia

Cocaine intoxication presents as a hypermetabolic state

Hematuria is not a symptom of hypermetabolic state

When assessing a patient with suspected cocaine intoxication, a nurse would expect to see:

Multisystem

Holistic Nursing CareOverdose CareMultisystem Care/ComplicationsShock Continuum

12/2015

Multisystem 9

Multisystem

Healthcare‐acquired infections

Infectious diseases

Thermoregulation

Bariatric complications

Rhabdomyolysis

Sleep disruption

Multisystem Care/Complications

Multisystem

Healthcare‐acquired infections CLABSI

CAUTI

VAP now part of ventilator‐associated events (VAE)

Opportunistic infections 

Multidrug‐resistant organisms (MRSA, VRE, CRE…MOUSE)

Vulnerable populations

Multisystem Care/Complications (cont)

Multisystem

Healthcare‐acquired infections CLABSI

CAUTI

VAP now part of VAE

Opportunistic infections 

Vulnerable populations

Multisystem Care/Complications (cont)

Prevention!Identification ofat-risk patientSurveillanceMonitoringSafety! Safety!

12/2015

Multisystem 10

Multisystem

Therapeutic hypothermia

Targeted temperature management√ Who?

√ When?

√ Why?

√ How—and how long?

√ Does it work?

Multisystem Care/Complications (cont)

Friberg H, et al. Resuscitation. 2015;90:158‐162.

Multisystem

Bariatric complications National epidemic

Medical complications

Multisystem Care/Complications (cont)

Multisystem

Source: http://www.asyouage.com/19_Medical_Complications_of_Obesity.html

12/2015

Multisystem 11

Multisystem

Bariatric complications National epidemic

Medical complications

Multisystem Care/Complications (cont)

Multisystem

Top 10: Clinical Challenges

1. Airway and ventilation

2. Cardiovascular

3. GI: ACS, aspiration

4. Hematological (DVT/PE)

5. Pharmacological dosing

6. Endocrine: Glucose control/nutrition

7. Diagnostic testing

8. Vascular access placement

9. Skin: Pressure ulcers/pressure‐induced rhabdomyolysis

10. Sensitive care challenges

Benefield A, et al. Challenges of the obese patient. NTI 2015.

Multisystem

Healthcare‐acquired infections

Infectious diseases

Thermoregulation

Bariatric complications

Rhabdomyolysis

Sleep Disruption

Multisystem Care/Complications (cont)

12/2015

Multisystem 12

Multisystem

Rhabdomyolysis: Rhabdo (striated) myo (muscle) lysis (breakdown)

Acute kidney injury

Myoglobinuric renal failure

Metabolic acidosis

Coagulopathies

Electrolyte disturbances

Multisystem

Rhabdomyolysis: Rhabdo (striated) myo (muscle) lysis (breakdown) (cont)

Acute kidney injury

Myoglobinuric renal failure

Metabolic acidosis

Coagulopathies

Electrolyte disturbances

Causes Trauma—BUT NOT just

trauma Direct or indirect Injury

to muscles Muscle ischemia Extreme temperatures Endocrine disorders Toxins Immobilization Exercise Burns/lighting

Multisystem

Rhabdomyolysis: Rhabdo (striated) myo (muscle) lysis (breakdown) (cont)

Acute kidney injury

Myoglobinuric renal failure

Metabolic acidosis

Coagulopathies

Electrolyte disturbances

Assessment/diagnosis BUN:creatinine

Serum CK

Myoglobinuria

Metabolic acidosis

Treatment Eliminate cause Support renal

clearance/function Urine output >150 mL/hr Intravascular volume

expansion Alkalinization of urine Mannitol and furosemide

(Lasix) Prevent further damage

12/2015

Multisystem 13

Multisystem

Healthcare‐acquired infections

Infectious diseases

Thermoregulation

Bariatric complications

Rhabdomyolysis

Sleep disruption

Multisystem Care/Complications

Multisystem

Sleep disruption Overstimulation (noise, physical, psychological)

Sleep apnea (obstructive and central)

Delirium

Pain 

Disrupted circadian rhythm

Stimulation of the immune and stress responses

Acute and chronic physiological and psychological complications

Multisystem Care/Complications (cont)

Multisystem

Causes Everything in acute care

Sleep Disruption

Treatment Prevention

Assessment and monitoring

Sleep protocols

Noise reduction

Patient focused routines

Sedatives?

Analgesics?

12/2015

Multisystem 14

Multisystem

Review Questions

Multisystem

Question 3

When providing care to a bariatric patient, the best weight to use for the tidal volume for the ventilator settings and propofol dosing is the:

A. Total body weight (TBW)

B. Ideal body weight (IBW)

C. Lean body weight (LBW)

D. Adjusted Body weight (ABW)

Multisystem

Question 3—Rationale

B. Ideal body weight (IBW)

Best to reflect chest size and total lung capacity, decreasing the risk of over‐ or underinflating the lungs

ABW = IBW + 0.4(actual – IBW) 

When providing care to a bariatric patient, the best weight to use for the tidal volume for the ventilator settings and propofol dosing is the:

12/2015

Multisystem 15

Multisystem

Question 4

A. Continuous venovenous hemofiltration 

B. Packed red blood cells, fresh frozen plasma

C. High‐volume fluid administration, 1 g mannitol

D. Dopamine infusion at 4 mcg/kg/min, 40 mg furosemide

A patient who was unresponsive upon being struck by lightning regained a pulse after an AED was used at the scene. Twenty‐four hours after admission to the ICU, the patient’s urine is cranberry/rust‐colored. Expected treatment would include:

Multisystem

Question 4—Rationale

C. High‐volume fluid administration, 1 g mannitol—Assessment indicates rhabdomyolysis, and infusing an osmotic diuretic will help to “flush” the myoglobin through and out the kidneys

Continuous venovenous hemofiltration—Indicated for AKD and patients too hemodynamically unstable to tolerate hemodialysis 

Packed red blood cells, fresh frozen plasma—Indicated for coagulopathy with symptomatic anemia

Dopamine infusion at 4 mcg/kg/min, 40 mg furosemide—Diuresis is a treatment for rhabdomyolysis; 4 mcg of dopamine is a vasopressor dose

A patient who was unresponsive upon being struck by lightning regained a pulse after an AED was used at the scene. Twenty‐four hours after admission to the ICU, the patient’s urine is cranberry/rust‐colored. Expected treatment would include:

Multisystem

Shock PathophysiologyPathogenesis andClassifications

12/2015

Multisystem 16

Multisystem

“A manifestation of the rude unhinging of the machinery of life”‒ Gross, 1872

“A momentary pause in the act of death”‒ John Collins Warren, 1895

Shock: Colloquial Definition

Multisystem

The inability of the circulatory system to supply oxygen and nutrients to the cells of the body

The oxygen demands are greater than the supply

Shock: Clinical Definition

Multisystem

Hypovolemic

Anaphylactic

Cardiogenic

Septic

Neurogenic

Classifications of Shock

12/2015

Multisystem 17

Multisystem

Most common

Easiest to treat

Blood volume is insufficient to fill the intravascular space

Preload deficit

Decrease in CO

Hypovolemic Shock

Multisystem

Absolute/direct loss of volume

External hemorrhage

Gastrointestinal volume losses

Renal volume losses

Plasma losses

Hypovolemic Shock: Causes

Multisystem

Relative/indirect loss of volume

Sequestration of fluid

Internal hemorrhage/volume losses

Vasodilation

Hypovolemic Shock: Causes (cont)

12/2015

Multisystem 18

Multisystem

Patient presentation will depend on:

Percent volume loss

Duration of hypovolemia 

Activation and response of compensatory mechanisms 

Hypovolemic Shock: Clinical Presentation

Multisystem

Restore intravascular volume

Stop loss of volume

Crystalloid or colloid?

Hypovolemic Shock: Therapeutic Goal

Multisystem

Loss of vasomotor tone 2◦ to inhibition of neural output

The loss of sympathetic tone allows the parasympathetic nervous system to dominate Vasodilation

Bradycardia

Decreased CO

Neurogenic Shock

12/2015

Multisystem 19

Multisystem

Spinal cord injury

Deep general anesthesia

Spinal anesthesia

Damage to the brain

Prolonged medullary ischemia

Central nervous system problems

Neurogenic Shock: Causes

Multisystem

Parasympathetic dominance

Vasodilation

Bradycardia

No motor or sensory

Neurogenic Shock: Clinical Presentation

Multisystem

Stop cause

Stabilize spine

Administer volume

Beta stimulation (heart rate)

Alpha stimulation (vasoconstrict)

Neurogenic Shock: Therapeutic Goal

12/2015

Multisystem 20

Multisystem

Massive vasodilation occurs because of an antigen‒antibody reaction, triggering of mast cells and basophils

Vasodilation

Increased capillary permeability

Hypotension

Relative hypovolemia

Anaphylactic Shock

Multisystem

Immunoglobulin E (IgE)—anaphylaxis

Non‐IgE—anaphylactoid (non antigen‒antibody)

Foods

Venoms

Blood products

Drugs

Anaphylactic Shock: Causes

Multisystem

Hypotension

Generalized edema (increased capillary permeability)

Laryngeal edema

Severe bronchoconstriction

Rash, itching, flushed skin

Angioedema 

Anaphylactic Shock: Clinical Presentation

12/2015

Multisystem 21

Multisystem

Identify and stop the cause

Block vasoactive mediators

Antihistamines

Vasoconstrictors

Bronchodilators

Fluid resuscitation

Anaphylactic Shock: Therapeutic Goal

Multisystem

Septic Shock

Multisystem

Sepsis

The systemic response to infection, manifested by ≥2 of the following conditions as a result of infection: 

Temperature >38◦C or <36◦C

Heart rate >90 

Respiratory rate >20 or PaC02 <32 mmHg

White blood cell count >12,000 or <4000 or 10% bands

Septic Shock: Definitions

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Crit Care Med. 1992;20(6):864-874.

12/2015

Multisystem 22

Multisystem

Systemic inflammatory response syndrome (SIRS)

The systemic inflammatory response to a variety of severe clinical insults. The response is manifested by ≥2 of the following conditions:

Temperature >38◦C or <36◦C

Heart rate >90 

Respiratory rate >20 or PaC02 <32 mmHg

White blood cell count >12,000 or <4000 or 10% bands

Septic Shock: Definitions (cont)

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Crit Care Med. 1992;(6):864-874.

Multisystem

MODS

The presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention

Septic Shock: Definitions (cont)

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Crit Care Med. 1992;(6):864-874.

Multisystem

Review Questions

12/2015

Multisystem 23

Multisystem

A. Temperature = 39°C, platelets = 72,000, positive D‐dimer

B. WBC 13.7, HR 127, RR 37

C. Hospital‐acquired pneumonia, WBC 11.5, pH 7.24

D. Temperature = 37.4°C, HR 54, glucose 210 

Question 5

Which of the following assessment data would increase suspicion that a patient is developing SIRS? 

Multisystem

Question 5—Rationale

B. WBC 13.7, HR 127, RR 37—SIRS criteria include high/low WBC, high/low HR, high/low RR, and high/low temp

Temperature 39°C, platelets 72,000, positive D‐dimer—D dimer is not part of the SIRS criteria

Hospital‐acquired pneumonia, WBC 11.5, pH 7.24—This diagnosis and pH are not part of SIRS criteria

Temperature 37.4°C, HR 54, glucose 210—Hyperglycemia is not part of SIRS criteria 

Which of the following assessment data would increase suspicion that a patient is developing SIRS? 

Multisystem

General variables

Inflammatory variables

Hemodynamic variables

Organ dysfunction

Tissue perfusion variables

Septic Shock: Definitions (cont)

Levy et al. Crit Care Med. 2003;31(4):1250‐1256.

12/2015

Multisystem 24

Multisystem

Infection

Bacteria, virus, fungi

Local  systemic  sepsis  septic shock

Septic Shock: Causes

Multisystem

Systemic reaction

Endotoxin and mediators

Inflammation

Inadequate delivery of oxygen

Massive vasodilation

Septic Shock: Clinical Presentation

Multisystem

Relative hypovolemia and hypoperfusion

Increased capillary permeability and edema

Myocardial depression

Lactic acidosis

Septic Shock: Clinical Presentation (cont)

12/2015

Multisystem 25

Multisystem

Pulmonary capillary leak leading to ARDS

Activation of complement system microthrombi

Platelet abnormalities

Gluconeogenesis and insulin resistance

Septic Shock: Clinical Presentation (cont)

Multisystem

Identify and stop cause

Block effects of inflammatory mediators

Antibiotics

Fluid resuscitation

Vasopressors

Ventilation and oxygenation

Restore hemopoietic balance

Septic Shock: Therapeutic Goal

Multisystem

Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis

and Septic ShockDellinger, et al. Crit Care Med. 2004;32(3);858-873.

18 evidence-based recommendations for caring for septic patients

Septic Shock: Therapeutic Goal (cont)

12/2015

Multisystem 26

Multisystem

2008 and 2012 Revisions of Surviving Sepsis Campaign Guidelines

for Management of Severe Sepsis and Septic Shock

Dellinger RP, et al. Crit Care Med. 2008;36(1):296-327.Dellinger, et al. Crit Care Med. 2013;41(2):580-637.

Septic Shock: Therapeutic Goal (cont)

Multisystem

Review Questions

Multisystem

A. HR 131, SVR 3500, CO 2.8 L/min

B. HR 61, SVR 600, 7.1 L/min

C. HR 127, SVR 450, CO 9.2 L/min

D. HR 140, SVR 2700, CO 10.2 L/min

Question 6

Which of the following hemodynamic variables would most likely be assessed in a patient with early septic shock?

12/2015

Multisystem 27

Multisystem

Question 6—Rationale

C. HR 127, SVR 450, CO 9.2 L/min—High HR due to decreased O2 delivery, low SVR from vasodilation from inflammatory mediator release, high CO from decrease afterload from vasodilation

HR 131, SVR 3500, CO 2.8 L/min—SVR would be low

HR 61, SVR 600, 7.1 L/min—HR would be high

HR 140, SVR 2700, CO 10.2 L/min—SVR would be low

Which of the following hemodynamic variables would most likely be assessed in a patient with early septic shock?

Multisystem

A. Tachycardia, hypotension, oliguria

B. Tachycardia, hyperthermia, hypotension

C. Hypertension, bradycardia, pitting edema

D. Hypotension, hyperglycemia, bibasilar rales

Question #7

Which of the following symptoms best describes the clinical assessment found with hypovolemic shock?

Multisystem

Question 7—Rationale

A. Tachycardia, hypotension, oliguria—High HR because of stimulation of compensatory response from low perfusion, low BP because of dehydration, low UO from decrease GFR and release of ADH to compensate for low BP

Tachycardia, hyperthermia, hypotension. Hypothermia would occur

Hypertension, bradycardia, pitting edema. Hypertension and pitting edema would present with hypervolemia

Hypotension, hyperglycemia, bibasilar rales. Lungs would be dry in hypovolemia

Which of the following symptoms best describes the clinical assessment found with hypovolemic shock?

12/2015

Multisystem 28

Multisystem

A. Hypotension

B. Bradycardia

C. Low urinary output

D. Low central venous pressure

Question #8

Which assessment data would help to differentiate neurogenic from anaphylactic shock?

Multisystem

Question 8—Rationale

B.  Bradycardia. Neurogenic shock would have bradycardia from parasympathetic dominance; anaphylactic shock would have tachycardia 

Hypotension. Both would have low BP

Low urinary output. Both would have low UO from low BP

Low central venous pressure. Both would have vasodilation

Which assessment data would help to differentiate neurogenic from anaphylactic shock?

Multisystem

NeurogenicAnaphylacticSeptic

Distributive Shock

Shock

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Hemodynamics in Shock

SHOCK

STATE

HR BP CO PAP CVP PAOP SVR

Hypovolemic High Low Low Low Low Low High

Cardiovascular High Low Low High High High High

Neurogenic Low Low Low Low Low Low Low

Anaphylactic High Low High/

low

Low Low Low Low

Septic High Low High/

low

Low Low Low Low

Multisystem

Stages of Shock

Multisystem

Stages of Shock (cont)

All cause hypoperfusion

Inadequate O2 supply

Inadequate CO

Aerobic  anaerobic metabolism

Lactic acidosis

Compensation for perfusion deficit

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Cytoplasm

2 ATP

Lactate

Anaerobic glycolysis

Citricacid cycle

O2

CO2

H2O

36ATP

Aerobicglycolysis

Aerobic vs Anaerobic Metabolism

Aerobic metabolism• CO2

• H2O

• 36 ATP

Anaerobic metabolism• 2 ATP

• Lactate

Glycogen Glucose Pyruvic acid

Multisystem

Stages of Shock (cont)

Compensatory stage Neural

Hormonal

Chemical

Decompensatory stage

Irreversible stage

Multisystem

Stage 1: Neural Compensation

Decreased O2 delivery from shock state

Vasomotor center

Stimulation of sympathetic nervous systemNorepinephrine and epinephrine release

Increase respiratory rate and tidal volume Increase heart rate 

and contractility

Vasodilate: Blood vessels in skeletal muscleVasoconstrict: GI tract, skin, kidneysDecrease urine output, peristalsis 

Increase blood flow to heart and brain

Coronary artery vasodilation

Pupils dilate,increase sweat production

GOAL: Increase cardiac output and improve O2 delivery

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Stage 1: Hormonal Compensation

Decreased oxygen delivery from shock state

Stimulation of sympathetic nervous system

GOAL: Increase water retention, blood pressure, cardiac output, glucose

Decrease renal GFR:Renin‐angiotensinaldosterone response

Increase osmolality:posterior pituitary anti‐diuretic hormone release

Anterior pituitary adrenocorticotropicAdrenal cortex gluocorticoids

Liver GluconeogenesisGlycogenolysis

Adrenal medullaStimulate epinephrine and norepinephrineSustain stress response

Multisystem

Stage 1: Chemical Compensation

Decreased oxygen delivery from shock state OUTCOME: Change in LOC, confusion, agitation, lethargy

Decrease blood flow to lungs

Ventilation > perfusion (dead space)Chemoreceptors identify drop in PaO2

Increase respiratory rate and tidal volumeDrop PaCO2

Vasomotor center medullaStimulate sympathetic 

nervous system

Respiratory alkalosisCerebral vasoconstriction

Cerebral ischemia

Multisystem

Stages of Shock: Decompensatory Stage

Compensatory mechanical failure

Arteriolar and precapillary sphincters require ATP for vasoconstriction

Sphincters relax

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Stages of Shock: Decompensatory Stage (cont)

Sludging of blood in capillaries

Microcirculation blocked

Metabolic acidosis

Chemical mediators released

Multisystem

Stages of Shock: Irreversible Stage

Refractory phase

No longer responds to treatment

Organ dysfunction

Organ failure

Multisystem

Shock is an imbalance between oxygen supply and demand

Hypoxia and/or ischemia initiate a cascade of tissue, organ, and cellular responses 

Cellular Response to Shock

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Cellular Injury

Infection/inflammation

Mediator release

Cap leakFree‐radical releaseCell deathVasodilation

Endothelial damage

MODSALI Cardiac Renal insufficiency DysfunctionLiver failure DIC, GI bleed

Multisystem

Cellular Injury (cont)

MODSARDS Cardiac Renal insufficiency DysfunctionLiver failure DIC, GI bleed

Death

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